Healthcare Provider Details

I. General information

NPI: 1114614872
Provider Name (Legal Business Name): CULLEN TOMME SHOWS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2023
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5360 I 55 N STE 150
JACKSON MS
39211-4055
US

IV. Provider business mailing address

PO BOX 301
STAR MS
39167-0301
US

V. Phone/Fax

Practice location:
  • Phone: 601-345-8200
  • Fax:
Mailing address:
  • Phone: 601-382-6325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number915744
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number906955
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: